This is a blog by a former CEO of a large Boston hospital to share thoughts about negotiation theory and practice, leadership training and mentoring, and teaching.

Tuesday, August 07, 2007

Sign in, please

In every room, we have a white board that is supposed to be used by the nurse on duty to note his or her name and other pertinent information for the patient and the patient's family. It is a handy, low-tech reference tool that is very helpful to people during their stay in the hospital.

Here is a note to me from a family member of a patient recently discharged. I am hoping nurses in our hospital and elsewhere will take something useful from this comment.

I noticed something funny during this hospital stay -- the white board has taken on an interesting life of its own. We had a nurse who did not use it. She turned out to be the kind of nurse who makes you nervous that she's not paying attention -- you know, the pain killer dose was not written in when it was given, that kind of thing. Then we realized: We felt that way from her first entry to the room, when she did not "sign in." It really is an interesting little step that makes you feel good. I don't understand it, but I sure like it.

19 comments:

John
said...

A friend of mine spent a lot of time at a local (Boston) hospital over the past two years. During that time, his wife became more of an expert in the doses of what he was to receive (and when) than the nurses attending to him. Not only was that frightening from HIS health point of view, but it simply made the rest of us scared to be hospitalized.

Their inattention to detail seemed truly callous and wholly unprofessional.

I think (and hope) that is unusual, John. Generally, the nurses I have seen -- at our place, for sure, and at others in town -- have been very, very good at what they do and how they do it. Our patient satisfaction surveys show very high marks for our nurses.

Defending your nursing staff's competence based on patient satisfaction surveys is like assessing your doctor's care based on his/her bedside manner. Nurses, in general, are caring, competent professionals, but there is no doubt that a significant percentage are lacking in some area. Since the average patient will see between 7 and 15 different nurses in a weeklong hospital stay, it only takes 1 in 20 "bad nurses" for it to end up that many patients will witness a mistake.

Re your comment: "there is no doubt that a significant percentage are lacking in some area". I guess that applies to all human beings! Are you saying that nurses do worse than other professionals in general or health care providers in particular? If so, I would have to disagree mightily based on what I see here.

Or, are you just saying that everyone in any job can improve? If so, of course, I would agree.

I have three chronically ill children, and have spent too much time in hosptials and out-patient clinics. I've found that even the most hardened and difficult nurse can be finessed - most of the time a little extra friendliness, and offer of a candy, or even an offer of a seat for just a few minutes is always welcomed. Even more so when you offer them a bit of the compassion that is expected of them.

However, when that doesn't work, usually a trip to the nurse manager, or floor supervisor often clears up whatever problem there was.

That being said, it always makes me worry about the patients who can't advocate for themselves, and don't have someone to do it for them.

I have yet to encounter a profession that doesn't have competent and incompetent people working at it (Regardless of the reason of incompetence, be it lack of knowledge or lack of desire). From doctors, to nurses, all the way down to the janitorial staff. I always try to give people the benefit of the doubt and assume it's a bad day rather than a bad career choice.

Putting your name on the board in the room is one of those Studor group recomendations to improve patient satisaction scores. Might be useful on the floor where the patients stay longer but I dont like it in the ER. Were also supposed to write goals for the patient below our names. I work in an ER that see's a lot of patients who I would rather they not know my name. As far as goals, If I had to be honest with the patient some very common goals would be Stop using meth, Stop smoking, Loose weight, Watch your language, Stop spitting, ect. I take issue with the point that not putting name on a board is somehow related to sloppy care.

If I can extend this example -- I think whenever you're in a foreign situation (like being in a hospital), especially where your anxiety level is high, it is often the little things, the things that register just below the level of active awareness, that indicate what the culture is like and whether you can trust the environment or not.

The nurse not signing the white board is a great example. For me, others include: Being dressed in real clothes rather than a johnny when you first meet the surgeon who is going to operate on you. The doctor or nurse looking you in the eye before they read your chart. The amount of listening the doctor or nurse does as compared with the amount of explaining. How clean the hallway bathrooms are (this is true for all public facilities). How the person at the information desk or the medical receptionist treats you.

Ironically, these little steps can make such a big difference to the patient, and my guess is that they are rarely included in professional training.

I think that healthcare in the US does way worse than other professions in general in acknowledging and fixing deficiencies at the same time that the level of competence expected and the % of those who achieve it is higher (sometimes considerably higher) than most professions. This yields to the curious anomaly of us throwing tremendous resources (both human and monetary) and achieving demostrably sub-optimal results.

This is an interesting discussion. A white board is especially important in the ER because in that environment it is stress-reducing for the patient. In the rooms, it does the same when you're sick. It's not just a symbol of good care to me. It wasn't the lack of signing in that made me think the nurse was sloppy -- it was her sloppiness that made me recall that she didn't sign in.

I think I'll stay anonymous since I wasn't the patient, just the family.

Most of all -- BID nurses are known far and wide for being the very best there are. They are serious about nursing and I have complete respect for them. I have visited patients in every hospital in town, and I think the BID team is the best.

Re: ED nurse assignments on a board, I had implemented at my former hospital a program of "care provider cards" which each member of a patient's care team filled out their name in the respective space (i.e. doctor, nurse, technician, resident, etc.). It was difficult enough getting staff to fill out this card (not much bigger than a business card).

After we had overcome this challenge, the housekeeper would be working double time to clean up all the cards that were thrown onto the floor and strewn around. Comments on the Press Ganeys indicated that the patients would rather have had an attentive care team that just introduced themselves rather than the cards, which were largely viewed as substitutes for verbal communication at times.

The white board feature in simple but ingenious. In our local hospital, we assign someone in the family to spend the first 15 min searching out current personel on the floor and getting a status update. The board sounds valuable to families and to the nursing staff.

To all the patients who have commented here: please consider that the nurse or tech caring for you may have just been so harried at the time you first met them that he or she forgot to sign the white board. The next time they come to see you, a simple comment like, "I think you forgot to sign the white board." will in the vast majority of cases lead to a heart felt apology and a much better relationship between you and your care givers. I am a tech, and it makes me feel terrible when a patient feels I or any of my coworkers have neglected them. A simple complaint gains my full attention. First, I listen. Then, I do whatever I can to make things right.

I am a nurse and I work some shifts up to 12 hours with no lunch break and I do not even sit down for a few minutes. I am trying so hard to get all of the things done that I have to do with 5 patients (or more) and I have no help! The nurses' aides are either lazy or overworked or otherwise unavailable and everyone has so many needs and it is difficult to be all things to all people. I realize that the public has no idea how hard it is to be a nurse. There is a nursing shortage because most people do not want to do this work. There is no glamour in cleaning up diarrhea or vomit. There is no joy in spending an hour and a half cleaning and comforting someone and feeling as though you have done a wonderful job only to encounter a hostile family member later in your shift who has no idea how well you cared for their loved one. I am getting out of nursing as soon as possible! I don't recommend it to anyone. In 10 years more families will be FORCED to do some of the dirty work themselves if it gets done at all.

With all of that said, I will certainly take into account "the little things" about which people have written. I always want to find ways to improve communication even though I've been doing this for 15 years! I got into nursing because I wanted to help people and all it takes is a little "thank you," some eye contact, understanding, a smile...but when a family member is hostile and dismissive, treating us like we are servants and not actual professionals who are well trained in areas beyond just passing pills (we advocate for patients more than the public can imagine), it makes it difficult to perform at our best. I have drawn negligent doctors' attention to life threatening conditions and of course I get no credit for that except from my coworkers who applaud my assessment skills. Please realize a nurse is your ally as well as the patient's ally and that nurses do very physically demanding, emotionally draining and stressful work and that unless you want to do that work yourself, you should be grateful that there are people who spend thousands of dollars on an education that makes them eligible for nursing licensure.

First, I can understand your frustrations. It takes courage to post your thoughts on nursing, even anonymously. I believe that nurses everywhere understand what you are saying and share similar feelings. Thank you for using your voice to reflect what happens to you professionally- I can relate.

You, as a nurse, do amazing things every day both seen and unseen. You change lives, you heal, and you make a difference! We are resourceful in even the most challenging situations (e.g. staffing shortages, patient loads, tragedy and even death). We are a team and we can find solutions-

There are specific tendencies inherent to role that reinforces stereotypes can be counterproductive for nursing. While this is overwhelming at times, it is no excuse for nurses to sit back and do nothing. We, as a profession, must empower one another and behave in ways that correspond with where we want to be as a group in the future.

There is a book out called From Silence to Voice by Bernice Buresh and Suzanne Gordon. It is a wonderful read on how nurses can become more effective in their environments. They prove that there are specific things that we can do to help the public better understand our role in the health care system especially as it relates to our introductions (Chapter 3 pages 42-56).

They talk about how we initially greet our patients. At the beginning of this blog trail Paul offered up that we should write it on a white board. I think that it is important to extend beyond that introduction. When we first walk into a patient’s room- we must identify ourselves professionally.

Compare and contrast how a physician enters the room, “Hello, my name Jon Smith and I am your doctor today”.

Notice that the doctor says both his/her first and last name and clearly identifies their role. This professional introduction creates the stage for the dialog between the provider and the patient.

Contrast: I have been a nurse for awhile now and it is not uncommon for nurses to introduce themselves this way: “I am Sally and I will be taking care of you today”. This leaves the patient unsure of Sally’s role. It also leaves a lot of room for interpretation. “Taking care of you today” could mean many different things, from changing a bedpan to saving a life.

Take an opportunity in that moment to show your stuff. “Hi my name is Sally Smith and I am a registered nurse who will be providing/coordinating your care today.” Talk about the patient’s diagnosis and plan for the day. It is almost like we need to advertise ourselves. This quote demonstrates the point well:

“In the world of work, people who receive credit often do so because they make it easy for others to acknowledge their contributions. A businessman we know, who first name is John, recalled that during his years as an employee in a large company, he made a point of introducing himself with his first and last name when he had an occasion to speak with the executive responsible for salaries. “I wanted him to be clear that I was the one who should get the raise, not some other John,” he says” (Buresh and Gordon 2006)

Nurses are an amazing group. Some of the most incredible people I know are nurses (I work with them everyday at Beth Israel). It is okay that we want to be acknowledged for what we do everyday. We will move forward as a profession if we are sensitive to the subtle things that influence our status in society. I think an introduction is a good place to start.

First, I can understand your frustrations. It takes courage to post your thoughts on nursing, even anonymously. I believe that nurses everywhere understand what you are saying and share similar feelings. Thank you for using your voice to reflect what happens to you professionally- I can relate.

You, as a nurse, do amazing things every day both seen and unseen. You change lives, you heal, and you make a difference! We are resourceful in even the most challenging situations (e.g. staffing shortages, patient loads, tragedy and even death). We are a team and we can find solutions-

There are specific tendencies inherent to role that reinforces stereotypes can be counterproductive for nursing. While this is overwhelming at times, it is no excuse for nurses to sit back and do nothing. We, as a profession, must empower one another and behave in ways that correspond with where we want to be as a group in the future.

There is a book out called From Silence to Voice by Bernice Buresh and Suzanne Gordon. It is a wonderful read on how nurses can become more effective in their environments. They prove that there are specific things that we can do to help the public better understand our role in the health care system especially as it relates to our introductions (Chapter 3 pages 42-56).

They talk about how we initially greet our patients. At the beginning of this blog trail Paul offered up that we should write it on a white board. I think that it is important to extend beyond that introduction. When we first walk into a patient’s room- we must identify ourselves professionally.

Compare and contrast how a physician enters the room, “Hello, my name Jon Smith and I am your doctor today”.

Notice that the doctor says both his/her first and last name and clearly identifies their role. This professional introduction creates the stage for the dialog between the provider and the patient.

Contrast: I have been a nurse for awhile now and it is not uncommon for nurses to introduce themselves this way: “I am Sally and I will be taking care of you today”. This leaves the patient unsure of Sally’s role. It also leaves a lot of room for interpretation. “Taking care of you today” could mean many different things, from changing a bedpan to saving a life.

Take an opportunity in that moment to show your stuff. “Hi my name is Sally Smith and I am a registered nurse who will be providing/coordinating your care today.” Talk about the patient’s diagnosis and plan for the day. It is almost like we need to advertise ourselves. This quote demonstrates the point well:

“In the world of work, people who receive credit often do so because they make it easy for others to acknowledge their contributions. A businessman we know, who first name is John, recalled that during his years as an employee in a large company, he made a point of introducing himself with his first and last name when he had an occasion to speak with the executive responsible for salaries. “I wanted him to be clear that I was the one who should get the raise, not some other John,” he says” (Buresh and Gordon 2006)

Nurses are an amazing group. Some of the most incredible people I know are nurses (I work with them everyday at Beth Israel). It is okay that we want to be acknowledged for what we do everyday. We will move forward as a profession if we are sensitive to the subtle things that influence our status in society. I think an introduction is a good place to start.